Understanding how auditors view claims is vital. Units of Service (especially pharmacy) can be considered hot buttons to auditors.

An auditor sees thousands of claims and develops a keen sense of medical necessity failures based on past experiences.  One example is seeing multiple modifiers 76, 77 or 59 to bypass edits and increase the Units of Service.

When looking at your claims for compliance, consider using Units of Service as the criteria, and look for the overuse of modifiers resulting in increased Units of Service for which the hospital would seek payment.

Look to see that the physician documented that these services were used in the diagnosis and treatment of the patient and how the patient is responding to treatment.  Look at the 76, 77 specifically for verbal orders – is there a pattern of ancillary staff ordering these without physician documentation as to the medical necessity in the record? Use the Units of Service to “triage” your claims.

This is the first in a series of audit tip blog posts that can help put your best foot forward on clean, compliant claims. Let us know if there are clean claim topics you’d like to hear about from an auditor’s perspective.

And, attend the Craneware Benchmark Series: Key Indicators of Revenue Integrity Excellence to understand how well your organization is performing against Craneware standards and, equally importantly, gather step-by-step best practices to minimize compliance risk and optimize financial performance.